How did Cheesecake Factory get to where they are? They studied what the best people were doing, figured out a way to standardize it, then looked for ways to bring it to everyone. Although we could look at research as medicine’s way of bringing new concepts forward, where we have fallen down as an industry and culture is our ability to deliver on this at the bedside. Why aren’t most myocardial infarction patients on beta-blockers? Why isn’t DVT prophylaxis universal? Why can’t we all wash our hands on a regular basis?
Medical care, especially the physician portion, has always placed an overwhelming bias on autonomy. We all know that even at the same hospital or within the same physician group of cardiologists or orthopedists (or even hospitalists) that there can be multiple ways to treat chest pain, replace a joint, or manage pneumonia. Dr. Gawande postulates that “customization should be 5%, not 95%, of what we do.” He is not suggesting cookbook medicine—rather, that we bring all of the current proven and consensus medical knowledge together and allow local professionals to agree to narrow their choices down to a consistent and reproducible process for managing care.
Hoag, a health network near my home in Orange County, Calif., has brought this approach to orthopedic care. Hoag purchased a smaller hospital near its main campus and is emphasizing state-of-the-art orthopedic care at the new facility. They aligned the incentives—clinically and financially—with a large but select group of orthopedists, and they have chosen just a few prosthetic choices for hip and knee replacements. They have narrowed their protocols for pre- and post-op care, and now do same-day joint replacements with lower complication rates and better return-to-activity results at lower costs. And trust me, the orthopedists at Hoag were as independent as any physicians you might run into. The demands of the new payor models and competition to provide consumers (i.e. patients) with a 21st-century experience pushed, pulled, and prodded these orthopedists, and an enlightened hospital leadership, to rise to the challenges.
HM Takeaway
So where do hospitalists fit into this emerging world of customer service, standardization, accountability for results, and payment change? As you might imagine, we are right in the middle of all of this. High-functioning HM groups have understood that we must help shape a better system for us to work in. We cannot perpetuate the old paradigm in which the hospital was simply a swap meet where each physician had a booth and performed a procedure with little regard to how efficient or effective the entire enterprise might be.
Hospitalists have always performed in a group setting and worked across the professional disciplines of medicine, surgery, and subspecialties, and with nurses, pharmacists, and therapists. In the best of breed, hospitalists are enculturated to think systemwide yet deliver to an individual patient.
As hospital chains look to standardize and deliver the best results and the most efficient use of resources, hospitalists can be positioned in a variety of ways. You can be an innovative partner, working with other professionals and the administration to seek new ways of doing things. You can be the manager or coordinator of other professionals and the rest of the team. But you also could evolve to be line workers and cogs in a larger machine, replaceable and commoditized. In the end, hospitalists will not only need to create value, but also position themselves to be professionally rewarded and respected for the value they create.
Dr. Gawande considers the perspectives of healthcare providers and patients as he looks to the future. “Patients won’t just look for the best specialist anymore; they’ll look for the best system,” he says. “Nurses and doctors will have to get used to delivering care in which our own convenience counts for less and the patients’ experience counts for more.”
